RESEARCH ARTICLES
Knowledge and practices about prevention of prostate cancer: a contribution to nursing
Andrei Boscarino de Menezes SilvaI; Cristiane Maria Amorim CostaII; Thelma SpíndolaIII; Raquel Conceição de Almeida RamosIV; Elizabeth Rose da Costa MartinsV; Marcio Tadeu Ribeiro FranciscoVI
INurse. Graduated at the State University of Rio de Janeiro. Brazil. Email: demenezesandrei@msn.com.
IINurse. Doctorate in Nursing. Assistant Professor of the Faculty of Nursing of the State University of Rio de Janeiro. Section Chief of the Urology of the University Hospital Pedro Ernesto. Rio de Janeiro, Brazil. Email: cristiane.costa@ig.com.br
IIIDoctorate in Nursing. Assistant Professor of the Faculty of Nursing of the State University of Rio de Janeiro. Brazil. Email: spindola@predialnet.com.br
IVNurse. Professor at the Faculty of Nursing at the State University of Rio de Janeiro. Nurse of the Piquet Carneiro Polyclinic and Urology at University Hospital Pedro Ernesto. Rio de Janeiro, Brazil. Email: raquel_rcar@msn.com
VNurse. Doctorate in Nursing. Assistant Professor of the Faculty of Nursing of the State University of Rio de Janeiro. Brazil. Email: oigresrose@uol.com.br
VINurse. Doctor. in Collective Health. Associate Professor of the Faculty of Nursing of the State University of Rio de Janeiro. Coordinator of the Nursing Degree Course at the University Veiga de Almeida. Rio de Janeiro, Brazil. E mail: mtadeu@uva.br
ABSTRACT: This study aimed to identify the knowledge of customers in relation to strategies for the prevention of prostate cancer, expressed by the National Policy for Integral Attention to Men's Health, and check with them, the realization of preventive examinations. This is an exploratory, descriptive study, conducted with 61 patients with multi-professional post attendance, of the health unit of the municipality of Rio de Janeiro. Data were collected through forms, after consultations, between March to May 2013. The tabulation and organization of data were defined with the support of Microsoft Office Excel 2010 program. The results showed that a significant number (8/13, 1%) of respondents who have no knowledge of prevention methods recommended by the Health Ministry and refrains from performing specific tests (22/36%) for the diagnosis of prostate cancer. It is concluded that men need greater clarification related to this disease preventive practices.
Keywords: Prostatic neoplasms; knowledge, attitudes and health practice; men's health; disease prevention.
INTRODUCTION
This study had as its object the users ' knowledge and practices in relation to the prevention of prostate cancer. The interest has arisen through the extension project of the State University of Rio de Janeiro (UERJ) Contributing to the prevention of prostate cancer developed in the urology infirmary of the University Hospital Pedro Ernesto and in the Center of Attention to Men's Health of Piquet Carneiro Polyclinic. In the developing of the project was noted that some men attended ignored the preventive measures of prostate cancer, even those who had already undergone procedures such as prostate biopsy and prostatectomy.
It was selected as a problem to this investigation: What the users ' knowledge and practices of a health care unit in relation to the prevention of prostate cancer? It is known that the National Policy of Integral Attention to Men's Health has focused on understanding the socio-cultural and institutional barriers and being important for the strategic proposition of measures that will promote the access of men to primary care services1. In many cases, is evidenced the reduced or no familiarity of respondents with the Politic2.
Given these considerations, it was determined as hypothesis: The lack of knowledge of the patients on the prevention of prostate cancer interferes with the practice of prevention, not carrying out preventive actions to pathology.
The objectives were: to identify the users ' knowledge regarding strategies for the prevention of prostate cancer, expressed by the National Policy of Integral Attention to Men's Health; and verify, with the users of the health unit, the realization of preventive examinations as recommended by this Policy.
This study can contribute to the improvement of care of health users, aiming to qualify the attention to health of the male population to ensure in particular the promotion of health and prevention of preventable diseases. In the area of education, must justify the construction of nurse's actions regarding to Human Health Policy. In the survey, you will be able to stimulate the scientific production in this area, considering the lack of publications about this subject.
LITERATURE REVIEW
The prostate is a small organ, shaped like an apple, located just below the bladder and in front of the rectum, involving the initial portion of the urethra3. For prevention of prostate cancer, rectal touch is the most employee test despite its limitations and used in association with the determination of prostate specific antigen (PSA), their sensitivity can reach 95%. The PSA is a glycoprotein originating in the prostate, and its high level in the bloodstream is considered an important biological marker for some prostate diseases, including cancer4.
The DRE can be characterized as one of the greatest fears of the patient in the moment of urological consultation, since the patient, during the exam has the experience of being penetrated, and may associate the exam as a violation, even if symbolic, of their masculinity. Associated to the difficulties for examination performance, there are barriers such as the cultural issue of masculinity and the difficulty for the man to occupy the role of patient who, frequently denies the possibility of being ill and seek medical attention, since they might be assuming a passive role, dependent and of fragility5. Other pointed difficulties, refers to a lack of routine health services and the lack of information6.
The recognition of social determinants in Brazil, that result in the vulnerability of the male population to harms to health, as well as the social representations about masculinity, which compromise the men access to primary care and critically affect the profile of this population health, directed the preparation, by the Health Ministry, the National Policy of Integral Attention to Men's Health7.
METHODOLOGY
Exploratory, descriptive, quantitative study developed in a health unit, located in the municipality of Rio de Janeiro, with attendance targeted towards male audiences and its aggravations. The study population was formed by patients who are in the period of screening for prostate cancer, aged 40 years and above. The period of data collection occurred between March and May of 2013, with 61 patients, selected through non-probability sample for accessibility or for convenience.
To compose the study were selected the following variables: length of screening for prostate cancer, prostate cancer negative diagnosis, sex, aged 40 years and above, urology consultation, realization of rectal exam.
The data were collected through the application of forms that were investigating: socio demographic profile; prevention strategies; risk factors; and profile of morbidities. Before application the form has been tested and validated.
All ethical requirements proposed by the Resolution No. 466/2012 of the National Health Council8 have been reputable. Thus, this project was submitted to the Committee of Ethics in Research of UERJ, getting the opinion of approval n° 221,704 in March 2013. Data collection was performed after the emission of this opinion and the authorization of the institution. Participants signed an Informed Consent Form, safeguarding their autonomy and anonymity.
The tabulation and organization of data have been defined with the support of the program Microsoft Office Excel 2010, being analyzed and discussed from the authors that discuss the subject.
RESULTS AND DISCUSSION
Social Profile
Of the customers approached, 9 (14.8%) were aged over 70 years, the age group with greatest prevalence was 61-70 years (22/36.1%), followed by 51-60 years (19/31.1%), and 40-50 years (11/18%). Prostate cancer is considered the senior cancer, since approximately three-quarters of the cases in the world occur with men from the age of 65 years3. It is important to note that the most prevalent age group in the study in question lies within a group at risk for developing prostate cancer9.
The data presented may suggest that the demand for ambulatory attendance at more advanced ages, as this investigation – from 61-70 years (22/36.1%), is connected with the appearance of symptoms of benign prostate growth, urinary urgency and nocturnal diuresis. Urinary incontinence is not part of normal aging, although the prevalence of the problem increases with age, being the elderly above 75 years the more probable group. So, with advanced age, the support of bladder neck, the functional length of the urethra and the competence of the pelvic floor, which offers additional support to the urethra, tend to decrease. The force of contraction of the detrusor muscles also reduces with age10. It should be also consider that it is in this age group there is a larger number of retirees, since an issue quite pointed to by men for not seeking primary care services is linked to his position of provider, claiming that the time of operation of health services coincides with the load time of the job. There is no denying that, on male concern, labor activity has a detached place, especially in people of lower social status, reinforcing the role historically assigned to the man of being responsible for the support of the family. Even though this may constitute, in many cases, an important barrier, will highlight that most women of all socioeconomic categories, integrates today a productive strength, with inclusion in the formal labor market, and it ceases to seek health services. Another point also pointed out is the difficulty of access to assistance services, claiming that, for appointments, will face endless queues that often cause the loss of a full day's work, without necessarily having their demands addressed in a single query11.
With regard to the economic characteristics of customers, 31 (50.8%) claim to receive up to two minimum wages per unit value of (R$763,14), highlighting the low purchasing power of the population studied. The financial aspect can be considered an interference factor for early diagnosis and treatment of pathology7.
The non valorization of the age recommended for the prevention of prostate cancer, which is 40-45 years, can increase the chances of worsening and sequelae caused by neoplasm and reduce the percentage of cure of the pathology in question12.
With regard to schooling, it is observed that most have Elementary School (24/39.4%), followed by the High School (19/31.1%). It is noteworthy that there is a reduced number of illiterates (04/6.6%). Accordingly, the level of education is a fundamental aspect for adherence to screening of prostate cancer, understanding the risk factors, knowledge of the disease and preventive measures. Health professionals should be alert to the degree of education of patients, so they can adapt the language to become more accessible to patients, in order to facilitate the understanding of health issues during the consultations7. There are authors who associate lack of information about the prevention or the treatment of prostate cancer to low levels of schooling and point out that the misinformation reaches in greater intensity the male population with lower educational level and socio-economic power, which demand educational activities geared mainly to this group13.
As for the survey of the family history of respondents against prostate cancer, 12 (19.7%) have relatives affected by cancer, with this precedent. It is known that family history of father or brother with prostate cancer before the age of 60 years of age is another important marker, which may increase the risk of 3 to 10 times compared to the general population and may reflect both inherited characteristics as shared lifestyles among family members4.
Knowledge about the prevention of prostate cancer
Given the objective of this study, are discussed in this topic, the knowledge (or ignorance) of the subjects on the prevention of prostate cancer.
It is worth noting that 53 (86.9%) respondents recognize the importance of carrying out annual preventive examinations for prostate cancer, as exposes the Table 1. Think in actions to demystify the subject of human health for greater adherence to prevention practices of prostate cancer is part of the health professional and health education strategies14.
AQUI DEVERÁ ENTRAR A TABELA 1
With respect to the knowledge of the participants of the research on which tests must be performed for the trace of prostate cancer, it was observed that 11 (18%) are unaware of the association of digital rectal examination with PSA as a preventive measure. Knowledge is a decisive factor in adopting these practices and attitudes against the recommended tests. This aspect assumes that health behaviors relate to a sequential process: the acquisition of a proper knowledge leads to a favorable attitude that can lead to healthy practices. With this, it is hoped that the appropriate knowledge is one of the features that encourage positive changes in behavior, although it is recognized that it is not the only determinant factor of health practices15.
Considering the sample, 41 (67.2%) participants do not have any knowledge about the risk factors, according to Table 1. The not understanding that lifestyle may interfere negatively, provides a relative increase in chances of development and evolution of prostate neoplasms. Without health education that lead to know the risk factors to reflect on the need for changes in habits of life, it will not be possible to change. Here also include heredity, which reinforces the need for changes in habits and achieving more early exam.
With respect to family history of prostate cancer, only three (4.9%) participants understand the heredity as a risk factor, the Table 1. A relatively low number considering that 12 (19.7%) have a history of familial prostate cancer. The high risk of developing prostate cancer, added to ignorance of heredity as risk factor, can be seen as a warning sign for health professionals about the knowledge of the risk factors associated with the age of completion of screening16.
In a study that aimed to identify the users ' knowledge related to the prevention of prostate cancer, it was observed that 65% of respondents knew nothing about prostate cancer. This misinformation has been identified as a factor that hinders the access to health promotion measures, diagnosis and early treatment of the pathology. It is up to health professionals providing prior information and guidance related to benefits surveys during any opportunity of contact with men who are in a period of screening for prostate cancer, a fact that will assist in the decision of realization or not of the examination17.
Practice of prevention of prostate cancer
Considering the prevention practices of the studied group, largely deprived of general exams (36/59%) and some (22/36.1%) of the specific for the diagnosis of prostate cancer, according to the Table 2.
HERE SHOULD ENTER THE TABLE 2
Such data reveal the close relationship between a culturally constructed model of masculinity and their influence on health care18. In relation to specific examinations for prostate cancer prevention it is noted that only 28 (45.9%) do the rectal combination associated with the PSA, according to Table 2. According to the Health Ministry, to achieve the early diagnosis of prostate cancer is necessary to use specific examinations to determine when the patient is healthy. The most commonly performed are: digital rectal examination, PSA and trans-rectal biopsy3. The prostate biopsy guided by ultrasonography has become the standard method for obtaining material for the pathology of the gland. From this principle it is important to note that the biopsy is performed at a later time, being used to consolidate the diagnosis of prostate cancer19.
The digital rectal examination is used to assess the size, shape and consistency of the prostate by checking the presence of nodules, however it is known that this examination has limitations, since it only allows palpation of the posterior and lateral portions of the prostate, but depend on the training and experience of the examiner4.
The best form of early detection is to use both the clinical as blood exam. In this sense, the best way to diagnose prostate cancer is represented by the combination of digital touch and dose of PSA. The exclusive touch fails in 30% to 40% of the cases, the PSA measures fail to 20%, but the joint implementation of the two exams fails to identify cancer at least 5% of patients19.
As regards the frequency of preventive prostate exams, the results show that predominate the patients that perform annually (25/41%) while others (14/23%) did not observe the period determined by the health authorities, according to the Table 2. Preventive measures and early diagnosis are two major benefits not valued, as the usual is to seek curative medicine4.
The diagnosis of cancer in advanced stage not only limits the effectiveness of treatment, the chances of cure, as it encourages the emergence of metastasis (tumor focus outside the place of origin). The recognition of the importance of early diagnosis is directly associated with the performance of the preventive examinations within the recommended period4.
In this study, only 27.2% of patients performed the beginning of the trace in the recommended time, from 45 years. Regarding the age of early screening in patients with affected relatives by prostate cancer, the findings show that only 2 (16.7%) held the first exam at the recommended age. It is need to register that patients with a family history of prostate cancer have an increased risk of developing cancer, so this particular group must have an extended knowledge of prevention practices12.
In front of the genetic prism, some risk factors should be highlighted: men with a family history of prostate cancer have a higher chance of developing the disease. The risks increase 2.2 times when a 1° degree relative (father or brother) is affected by the problem, of 4.9 times with two relatives of 1° degree and 10.9 times with three relatives of 1° degree. In the hereditary cases, the cancer manifests itself more prematurely, before the age of 50 years. For this reason, men with a family history should perform preventive examinations from the 40 years. Heredity of prostate cancer can be ratified when it becomes apparent that if one identical twin has the disease, the risk of their brother to develop the disease is 27%, while among non-identical twins this risk is only 7%16.
It can be observed that 14 (22.9%) initiated the trace of cancer on their own and that 34 (55.7%) began screening for indication of health professionals, demonstrating the importance of raising awareness and informing the population about the risk factors of prostate cancer, as well as the importance of early diagnosis and treatment. The male population have been breaking paradigms, fears and putting themselves in a new level of awareness about their own health.
A few years ago, the public health system has made available to the population the realization of examination for the prevention of prostate cancer. However, a study reported that, possibly as a result of man do not have the habit of looking for the health service, even in the presence of complaints. When it comes to such examination, the adoption of preventive conduct is also blocked by prejudice, in addition to the health education deficit of the population inherent to prevention. Thus, most met did not perform the disease prevention, apparently unaware the etiology and possible signs and characteristic symptoms, as well as the conduct to detect it early17.
Nursing in the prevention of prostate cancer
Various difficulties can be found in the prevention of prostate cancer. As evidenced in the study, some are mainly related to the lack of information. In this context, the nurse can provide information related to human health and guide them with regard to the prevention of diseases and the maintenance of health, as well as identify the presence or absence of risk factors and to look for signs and symptoms that might indicate related changes20.
Considering the high rate of men who don't know the risk factors for prostate cancer (41/67.2%), the nurse becomes essential in the educational processes in health and preventive care, and to plan and evaluate the care offered to male population “in order to achieve well-being and better conditions for maintenance of health”17:216, in addition to establishing strategies focused to the specificity of the male gender.
The nurse emphasizes as an educator among professionals in the area of health, because it has experience with the educational process from the academic time. The nursing presented as goals the care and teaching, acting along the patients, seeking behavior change and enabling health promotion17.
“The approach of men in nursing consultation may contribute to the identification of risk factors, signs and symptoms of possible changes”20:386 that aid in their motivation for the examination of trace and consequent prevention.
The role of the nurse in health care is as important as the intended for woman, in other words, the prostate cancer needs to be so debated and valued as the cervical-uterine cancer and breast cancer21.
CONCLUSION
This research assessed the knowledge of users of a core of attention to men's health of Rio de Janeiro municipality in relation to the prevention of prostate cancer. The results indicate that there is a significant number of respondents who has no knowledge of prevention methods recommended by the Health Ministry; a large portion of the studied group was unable to identify the risk factors associated with prostate cancer, even after receiving information regarding the subject; it was noted a difficulty in assimilating knowledge with preventive practices. Still, it was noted in the findings that some patients with family history of prostate cancer, did not start the tracing process within the recommended period. This particular group has an increased risk of developing cancer and must receive an expanded knowledge of practices for the prevention of prostate cancer.
The lack of knowledge of the participants of the study about the risk factors of prostate cancer and the cultural aspects – especially the issue of masculinity and the fear – and the difficulty of access to treatment centers arise as a barrier, hindering the accession and expose the weakness of individuals before their citizenship rights. Given the above, it is clear the need of nurses in the orientation, providing information about risk factors and aspects relating to changes that can occur in the prostate and how preventive examinations are performed and the recommended age for the beginning of that control. This action becomes necessary to demystify and breaking paradigms built throughout history.
Among the limitations of the study, it is emphasize the reduced sample and a single scenario that prevent the generalization of the findings.
The development of new research stands in knowledge gaps regarding the subject. It is suggested other studies related to the knowledge of health professionals about the risk factors, age of early prostate cancer screening, period for forwarding of patient to the urologist and guidance to be given to patients.
REFERENCES
1. Ministério da Saúde (Br). Secretária de Atenção a Saúde. Departamento de Ações Programáticas Estratégicas. Política Nacional de Atenção Integral à Saúde do Homem. Brasília (DF): Editora MS; 2008.
2. Gomes R, Leal AF, Knauth D, Silva GSN. Sentidos atribuídos à política voltada para a saúde do homem. Ciência saúde coletiva. 2012;17;10. [citado em 02 nov 2012] Available at: http://dx.doi.org/10.1590/S1413-81232012001000008
3. Ministério da Saúde (Br). Instituto Nacional do Câncer. Próstata. Brasília (DF): Editora MS;2010. [citado em 15 ouit 2012]. Available at: http://p://www2.inca.gov.br/wps/wcm/connect/tiposdecancer/site/home/prostata/definição
4. Ministério da Saúde (Br). Secretaria Nacional de Assistência à Saúde. Instituto Nacional de Câncer. Coordenação de Prevenção e Vigilância - Conprev. Câncer da próstata: consenso. Rio de Janeiro: INCA; 2002.
5. Gomes R, Nascimento EF, Rebello LEFS , Araujo, FC. As arranhaduras da masculinidade: uma discussão sobre o toque retal como medida de prevenção do câncer prostático. Ciência saúde coletiva. 2008; 13:75-84. [citado em 22 out 2012] Available at: http://dx.doi.org/10.1590/S1413-81232008000600033.
6. Pinho IC, Siqueira JCB, Pinho LMO. As percepções do enfermeiro acerca da integralidade da assistência. Revista Eletrônica de Enfermagem, 2006; 8:42-51.[citado em 12 nov 2012] Available at: http://www.revistas.ufg.br/index.php/fen.
7. Ministério da Saúde (Br). Portaria MS/GM nº 1.944 de 27 de agosto de 2009. Institui no âmbito do Sistema Único de Saúde (SUS), a Política Nacional de Atenção Integral à Saúde do Homem. [citado em 08 nov 2012]. Available at: http://bvsms.saude.gov.br/bvs/saudelegis/gm/2009/prt1944_27_08_2009.html.
8. Ministério da Saúde (Br). Diretrizes e normas regulamentadoras de pesquisas em seres humanos. Resolução nº 466 de 12 de dezembro de 2012. Brasília (DF): CNS;2012.
9. Ministério da Saúde (Br). Instituto Nacional do Câncer. Incidência de câncer no Brasil. Brasília (DF), 2012. [citado em 03 nov 2012] Available at: http://www.inca.gov.br/estimativa/2012/index.asp?id=5
10. Guccione AA. Fisioterapia geriátrica. 2ª ed. Rio de Janeiro: Guanabara Koogan; 2002.
11. Kalckmann S, Batista LE, Souza, LCF. Homens de baixa renda falam sobre saúde reprodutiva e sexual. In: Adorno R, Alvarenga A, Vasconcelos MP, organizadores. Jovens, trajetória, masculinidades e direitos. São Paulo: Edusp; 2005. p. 199-217
12. Sociedade Brasileira de Urologia. Exame periódico de câncer de próstata. Bahia, 2007. [citado em 11 maio 2013]. Available at: http://www.simplescomunicacao.com.br/sbu/artigo.php?ca=1.
13. Paiva EP, Motta MCS, Griep, RH. Barreiras em relação aos exames de rastreamento do câncer de próstata. Rev Latino-Am Enfemagem. 2011;19:1. [citado em 02 nov 2012] Available at: www.eerp.usp.br/rlae
14. Nascimento MR. Câncer de próstata e masculinidade: motivações e barreiras para a realização do diagnóstico precoce da doença. [citado em 25 jun 2013]. Available at: http://www.abesp.nepo.unicamp.br
15. Paiva EP, Motta MCS, Griep RH. Conhecimentos, atitudes e práticas acerca da detecção do câncer de próstata. Acta Paulista Enferm. 2010;23: 88-93.
16. Seabra DDG. Câncer de próstata hereditário. Revista uronline. 1998. [citado em 15 out 2012] Available at: http://www.uronline.unifesp.br/uronline/ed1098/cancer.htm.
17. Vieira LJES, Santos ZMSA, Landim FLP, Caetano JÁ, Sá Neta CA. Prevenção do câncer de próstata na ótica do usuário portador de hipertensão e diabetes. Ciência e Saúde Coletiva. 2008;13:145-52.
18. Gomes R, Nascimento EF, Araújo FC. Por que os homens buscam menos os serviços de saúde do que as mulheres? As explicações de homens com baixa escolaridade e homens com ensino superior. Cad Saúde Pública. 2007;23:565-74.
19. Srougi M. Câncer de próstata: uma opinião médica. [citado em 15 out 2012] Available at: http://www.unifesp.br/dcir/urologia/uroline/ed1098/tela.htm.
20. Medeiros AP, Menezes MFB, Napoleão AA. Fatores de risco e medidas de prevenção do câncer de próstata: subsídios para a enfermagem. Rev Bras Enferm. 2011;64:385-8.
21. Mesquita MGR, Moreira MC, Malisk S. Em busca de conhecimento de enfermagem sobre o homem com câncer: uma experiência internacional. Escola Anna Nery.2009;13:421-4.